Provider Demographics
NPI:1215462726
Name:BURGESS, MARSHAREE'
Entity type:Individual
Prefix:
First Name:MARSHAREE'
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 TROUP ST
Mailing Address - Street 2:CATHOLIC FAMILY CENTER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-2053
Mailing Address - Country:US
Mailing Address - Phone:585-336-9034
Mailing Address - Fax:585-423-2201
Practice Address - Street 1:55 TROUP ST
Practice Address - Street 2:CATHOLIC FAMILY CENTER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-2053
Practice Address - Country:US
Practice Address - Phone:585-336-9034
Practice Address - Fax:585-423-2201
Is Sole Proprietor?:No
Enumeration Date:2017-04-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324889-1103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY324889-1Medicaid
NY324889-1Medicare UPIN
NY324889-1Medicare PIN